Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45769 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–1504–N] 

RIN 0938–AQ08 

Medicare Program; Changes to the 

Hospital Outpatient Prospective 

Payment System and Ambulatory 

Surgical Center Payment System for 

CY 2010, and Extension of Part B 

Payment for Services Furnished by 

Hospitals or Clinics Operated by the 

Indian Health Service, Indian Tribes, or 

Tribal Organizations Made by the 

Affordable Care Act 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This Notice contains the final 

wage indices, hospital reclassifications, 

payment rates, impacts and addenda for 

payments made under the Medicare 

hospital outpatient payment system 

(OPPS) for CY 2010. This Notice also 

contains the payment rates and addenda 

for payments made under the Medicare 

Ambulatory Surgical Center (ASC) 

payment system for CY 2010. The final 

rates, wage indices, addenda and 

impacts for the OPPS and as applicable 

for the ASC payment system contained 

in this Notice reflect the provisions of 

the Affordable Care Act. It also 

announces the extension of payment 

under Medicare Part B to hospitals and 

ambulatory care clinics operated by the 

Indian Health Service, Indian Tribes, or 

Tribal Organizations. 

DATES: Effective Date: The revised CY 

2010 national unadjusted OPPS and 

ASC payment rates described in this 

Notice are effective for payments for 

services furnished on or after January 1, 

2010. 

FOR FURTHER INFORMATION CONTACT: 

Alberta Dwivedi, (410) 786–0378. 

SUPPLEMENTARY INFORMATION: 

I. Provisions of the Notice 

A. Medicare Hospital Outpatient 

Prospective Payment System (OPPS) 

1. Background 

We finalized changes to the payment 

rates and factors under the hospital 

outpatient prospective payment system 

(OPPS) in the CY 2010 OPPS/ASC final 

rule with comment period appearing in 

the November 20, 2009 Federal 

Register. On March 23, 2010, 

subsequent to the publication of the CY 

2010 OPPS/ASC final rule, the Patient 

Protection and Affordable Care Act 

(Pub. L. 111–148) was signed into law. 

Shortly thereafter, on March 30, 2010, 

the Health Care and Education 

Reconciliation Act of 2010 (Pub. L. 111– 

152) was signed into law. These two 

laws are discussed in this Notice and 

are collectively referred to as the 

‘‘Affordable Care Act’’ throughout this 

Notice. As discussed in detail below, 

several provisions of these public laws 

revised components of the OPPS, and 

those revisions required us to revise the 

payment rates and various factors under 

the CY 2010 OPPS. This Notice 

addresses the provisions of the 

Affordable Care Act that impact the CY 

2010 OPPS final wage index tables, 

rates, and impacts. We note that the 

payment rates and policies set forth in 

the CY 2010 OPPS/ASC final rule with 

comment period appearing in the 

November 20, 2009 Federal Register 

continue to apply to those aspects of the 

OPPS that are unaffected by the 

Affordable Care Act. This Notice makes 

no changes to the OPPS payment 

methodologies or policies. 

2. CY 2010 OPPS OPD Fee Schedule 

Increase Factor 

Section 1833(t)(3)(C)(ii) of the Act 

requires us to update the conversion 

factor used to determine payment rates 

under the OPPS on an annual basis 

using the OPD fee schedule increase 

factor in 1833(t)(3)(C)(iv) of the Act for 

the year involved. For purposes of 

section 1833(t)(3)(C)(iv) of the Act, 

subject to 1833(t)(17) and 1833(t)(3)(F), 

the OPD fee schedule increase factor is 

equal to the market basket percentage 

increase applicable under section 

1886(b)(3)(B)(iii) of the Act to hospital 

discharges occurring during the fiscal 

year ending in such year, reduced by 1 

percentage point for such factor for 

services furnished in each of 2000 and 

2002. In addition, under 1833(t)(17) of 

the Act, hospitals that fail to meet the 

reporting requirements of the Hospital 

Outpatient Quality Data Reporting 

Program (HOP QDRP) are subject to a 

reduction of 2.0 percentage points from 

the OPD fee schedule increase factor. In 

accordance with 1833(t)(3)(C)(iv), the 

CY 2010 OPD fee schedule increase 

factor (commonly referred to as the 

‘‘hospital operating market basket 

increase factor’’) finalized in the CY 

2010 OPPS final rule was 2.1 percent 

(74 FR 60419). In addition, under the 

CY 2010 OPPS/ASC final rule (74 FR 

60419), a hospital that fails to meet the 

reporting requirements of the HOP 

QDRP reporting requirements receives a 

.1 percent update (that is, the CY 2010 

estimate of the OPD fee schedule 

increase factor of 2.1 percent minus 2.0 

percentage points) for services to which 

the OPD fee schedule increase factor 

applies. 

Section 1833(t)(3)(F)(ii) and (G)(i) of 

the Social Security Act, as added by 

section 3401(i) of the Public Law 111– 

148, and as amended by section 

10319(g) of such Act and section 1105(e) 

of Public Law 111–152, required the 

Secretary after calculating the OPD fee 

schedule increase factor, to reduce such 

factor by an adjustment of 0.25 

percentage point, effective for services 

furnished on or after January 1, 2010 

and before January 1, 2011. (In addition, 

new 1833(t)(3)(F) of the Act also 

provides that application of this 

subparagraph [1833(t)(3)(F)] may result 

in the increase factor under section 

1833(t)(3)(C)(iv) of the Act being less 

than 0.0 for a year, and may result in 

payment rates under the payment 

system under this subsection for a year 

being less than such payment rates for 

the preceding year.) Therefore, the 

reduction of 0.25 percentage point 

applied to the full hospital operating 

market basket increase factor of 2.1 

percent results in a revised hospital 

operating market basket increase factor 

of 1.85 percent. A hospital that failed to 

meet the reporting requirements of the 

HOP QDRP reporting requirements 

receives a negative 0.15 percent hospital 

operating market basket increase factor 

(that is, the revised hospital operating 

market basket increase factor of 1.85 

percent minus 2.0 percentage points.) 

3. CY 2010 OPPS Conversion Factor 

To calculate the OPPS conversion 

factor for CY 2010 in the CY 2010 

OPPS/ASC final rule with comment 

period (74 FR 60419), we increased the 

CY 2009 conversion factor of $66.059 by 

2.1 percent. We then adjusted the 

conversion factor for CY 2010 to ensure 

that any revisions we made to our 

updates for a revised wage index and 

rural adjustment were budget neutral. 

We calculated an overall budget 

neutrality factor of 0.9997 for wage 

index changes by comparing total 

payments from our simulation model 

using the FY 2010 IPPS final wage index 

values to those total payments using the 

FY 2009 IPPS final wage index values. 

For CY 2010, we did not propose a 

change to our rural adjustment policy. 

Therefore, the budget neutrality factor 

for the rural adjustment was 1.0000. For 

the CY 2010 OPPS/ASC final rule, we 

estimated that pass-through spending 

for both drugs and biologicals and 

devices for CY 2010 will equal 

approximately $45.5 million, which 

represents 0.14 percent of total 

projected CY 2010 OPPS spending. 

Therefore, the conversion factor was 

also adjusted by the difference between 

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the 0.11 percent estimate of passthrough spending set aside for CY 2009 

and the 0.14 percent estimate for CY 

2010 pass-through spending. Finally, 

estimated payments for outliers remain 

at 1.0 percent of total OPPS payments 

for CY 2010. In our November 20, 2009 

CY 2010 OPPS/ASC final rule with 

public comment, we announced a full 

conversion factor of $67.406 for the CY 

2010 OPPS. 

As indicated previously, hospitals 

that fail to meet the reporting 

requirements of the Hospital Outpatient 

Quality Data Reporting Program (HOP 

QDRP) are subject to a reduction of 2.0 

percentage points from the OPD fee 

schedule increase factor, which is 

applied to the conversion factor that is 

used to calculate their payment rates. To 

calculate the CY 2010 reduced OPD fee 

schedule increase factor for those 

hospitals that fail to meet the 

requirements of the HOP QDRP for the 

full CY 2010 payment update in the CY 

2010 OPPS/ASC final rule, we made all 

other adjustments described above, but 

used a reduced OPD fee schedule 

increase factor of 0.1 percent. This 

resulted in a reduced conversion factor 

of $66.086 for those hospitals that fail to 

meet the HOP QDRP reporting 

requirements. 

As discussed previously, section 

1833(t)(3)(F)(ii) and (G)(i) of the Social 

Security Act, as added by section 

3401(i) of the Affordable Care Act, and 

as amended by section 10319(g) of such 

Act and section 1105(e) of Public Law 

111–152, requires the Secretary, after 

calculating the OPD fee schedule 

increase factor, to reduce such factor by 

an adjustment of 0.25 percentage point 

effective for services furnished on and 

after January 1, 2010 through December 

31, 2010. Moreover, as discussed in 

more detail in section I.A.4 below, 

section 3137 of the Affordable Care Act 

extended section 508 reclassifications 

and special exception wage indices from 

October 1, 2009 to September 30, 2010. 

Section 3137(a) also required the 

Secretary, for the second half of the 

year, to recalculate wage indices by 

excluding section 508 and special 

exception hospital wage data in certain 

circumstances. The OPPS adopts the 

final fiscal year IPPS wage index on a 

calendar year basis. We use both the 

OPD fee schedule increase factor and 

the budget neutrality adjustment which 

accounts for the effects of adopting the 

new fiscal year IPPS wage index on a 

calendar year basis in the calculation of 

the OPPS conversion factor. Therefore, 

the reduction of 0.25 percentage point 

applied to the OPD fee schedule 

increase factor of 2.1 percent and the 

revised wage index budget neutrality 

factor of 0.9997 required us to 

recalculate the CY 2010 OPPS 

conversion factor. We note that none of 

the other components of the conversion 

factor calculation, specifically the 

adjustment to account for estimated cost 

of pass through drugs and nonimplantable biologicals, and device 

categories and the proportion of 

estimated total OPPS payments for 

outlier payments changed as a result of 

the provisions of Affordable Care Act. 

The budget neutrality adjustment for the 

rural adjustment continues to be 1.0000 

because we did not propose and the 

Affordable Care Act did not authorize 

any changes to the rural adjustment. 

Therefore, the only changes to the 

conversion factor, and thus to the CY 

2010 OPPS payment rates, that are 

reflected in this Notice are caused by 

the statutorily required reduction 

applied to the OPD fee schedule 

increase factor and the statutory changes 

to the wage index. 

To calculate the revised OPPS 

conversion factor for CY 2010 that is 

effective for covered OPD services 

furnished on or after January 1, 2010 

through December 31, 2010, we used the 

same methodology that was used in the 

CY 2010 OPPS/ASC final rule (74 FR 

60419). We first increased the CY 2009 

conversion factor of $66.059 by the 

revised OPD fee schedule increase factor 

of 1.85 percent (2.1 percent which is the 

full inpatient operating market basket 

percentage increase applicable to 

hospital discharges under section 

1886(b)(3)(B)(iii) of the Act less the 0.25 

percentage point reduction) for CY 

2010. We further adjusted the 

conversion factor to ensure that any 

revisions we made to our updates 

accounting for the statutorily required 

changes to the wage index were made 

on a budget neutral basis. We calculated 

an overall budget neutrality adjustment 

factor of 0.9997 for wage index changes 

by comparing total payments from our 

simulation model using the FY 2010 

IPPS final wage index values, as 

adjusted by the Affordable Care Act (see 

discussion in section I.A.4.), to those 

payments using the final FY 2009 IPPS 

wage index values and multiplied this 

by the conversion factor which already 

was adjusted to reflect the revised OPD 

fee schedule increase factor. For 

purposes of calculating the overall 

budget neutrality adjustment for wage 

index changes, we created a single CY 

2010 average wage index with 50 

percent of the wage index in effect 

between January 1, 2010 and June 30, 

2010 and 50 percent of the wage index 

in effect between July 1, 2010 and 

December 31, 2010. We note that the 

wage index adjustment of 0.9997 that 

we recalculated using the wage index 

values that resulted from the Affordable 

Care Act provisions is identical (when 

rounded to the 4th decimal) to the wage 

index adjustment that we calculated for 

the CY 2010 OPPS conversion factor 

that we published on November 20, 

2009. Next, we multiplied the wage 

adjusted conversion factor by the budget 

neutrality factor for the rural adjustment 

of 1.0000 that was finalized in the CY 

2010 OPPS/ASC final rule (74 FR 

60419). Therefore, the final revised full 

conversion factor for CY 2010 resulting 

from the above-described steps is 

$67.241 for services furnished on and 

after January 1, 2010 and before January 

1, 2011. We then adjusted the CY 2009 

conversion factor to reflect changes in 

our estimate of total OPPS expenditures 

that would be dedicated to pass-through 

payments in CY 2010 that were 

finalized in the CY 2010 OPPS/ASC 

final rule (74 FR 60419). Finally, 

estimated payments for outliers 

remained at 1.0 percent of total OPPS 

payments for CY 2010 (74 FR 60419). 

To calculate the revised final CY 2010 

reduced market basket conversion factor 

for those hospitals that fail to meet the 

requirements of the HOP QDRP for the 

full CY 2010 payment update, we used 

the same methodology and adjustments 

discussed above, except that we used a 

reduced OPD fee schedule increase 

factor of negative 0.15 percent (that is, 

the revised OPD fee schedule increase 

factor of 1.85 percent minus 2.0 

percentage points). This resulted in a 

final reduced conversion factor for CY 

2010 of $65.921 for those hospitals that 

fail to meet the HOP QDRP requirement 

effective for covered OPD services 

furnished on or after January 1, 2010 

through December 31, 2010. To 

calculate the reduced payment for these 

hospitals in our claims processing 

systems we apply a reduction ratio, that 

we refer to as the ‘‘reporting ratio’’ of 

0.980, which remains unchanged from 

the reporting ratio we published on 

November 20, 2009 (74 FR 60641), 

notwithstanding the changes to the 

hospital operating market basket and 

wage index values for some hospitals 

required by the Affordable Care Act. 

The recalculated CY 2010 final 

conversion factor of $67.241 is reflected 

in the revised CY 2010 OPPS payment 

rates and rate dependent files that are 

posted on the CMS Web site at http:// 

www.cms.gov/HospitalOutpatientPPS/. 

Because the conversion factor was 

revised, we were required to recalculate 

a number of aspects of the CY 2010 

OPPS using our established 

methodologies as set forth in the CY 

2010 OPPS/ASC final rule (74 FR 

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60316) using the revised conversion 

factor, including the OPPS payment 

rates that rely on the conversion factor 

and other components of the payment 

system that depend on OPPS payment 

rates for CY 2010 OPPS using our 

established methodologies to take this 

revision into account. 

These include CY 2010 OPPS APC 

payment rates that are printed in 

Addenda A and B of this Notice. We use 

the conversion factor to calculate OPPS 

payment rates for services in APCs with 

the following status indicators, ‘‘P’’, 

‘‘Q1’’, ‘‘Q2’’, ‘‘Q3’’, ‘‘R’’, ‘‘S’’, ‘‘T’’, ‘‘V’’, ‘‘X’’, 

and ‘‘U’’. The components of the 

payment system that are impacted by 

these changes include: The offset 

amounts for devices (devices and 

implantable biologicals), ‘‘policy 

packaged’’ drugs (diagnostic 

radiopharmaceuticals and contrast 

agents), and ‘‘threshold packaged’’ drugs 

(drugs and non-implantable biologicals 

that maybe packaged under the drug 

packaging threshold) that are used for 

assessment of pass-through applications 

and reductions to payment for certain 

device-dependent procedures, nuclear 

medicine procedures, or other imaging 

procedures using contrast agents, when 

a diagnostic radiopharmaceutical, 

device or implantable biological, or 

contrast agent is receiving pass through 

payment (74 FR 60462 through 60463, 

and 60480 through 60484). The revised 

offset amounts are not published as 

addenda to OPPS update rules but are 

available at www.cms.hhs.gov/ 

HospitalOutpatientPPS/ under ‘‘Annual 

Policy Files.’’ These revisions are 

effective for covered OPD services 

furnished on or after January 1, 2010 

through December 31, 2010. 

The offset amount for each group of 

items, devices, ‘‘threshold packaged’’ 

drugs and nonimplantable biologicals, 

and ‘‘policy packaged’’ drugs and 

biologicals, are calculated using the 

same methodology. For a discussion of 

the methodology we use for devices and 

implantable biologicals, see our CY 

2008 final rule with comment period (72 

FR 66751 through 66752 and 74 FR 

60463), and for our discussion of the 

methodology we use for diagnostic 

radiopharmaceuticals and contrast 

agents, see our CY 2010 final rule with 

comment period discussion at 74 FR 

60482. We use these offset amounts in 

our cost significance calculation when 

evaluating an application for passthrough payment for both drugs and 

nonimplantable biologicals, and devices 

including implantable biologicals. 

Finally, for a subset of the devicedependent procedures, we reduce OPPS 

payment by the device offset amount 

when a hospital furnishes a device 

received at no cost or full credit and by 

half of the device offset amount when a 

hospital furnishes a device received for 

partial credit (74 FR 60464 through 

60466). 

4. Revision of Hospital Wage Index 

Values for CY 2010 as Required by 

Section 3137(a) of Affordable Care Act 

Section 1833(t)(2)(D) of the Act 

requires the Secretary to determine a 

wage adjustment factor to adjust, for 

geographic wage differences, the portion 

of the OPPS payment rate, which 

includes copayment, that is attributable 

to labor and labor-related cost. This 

adjustment must be made in a budget 

neutral manner. The OPPS labor-related 

share is 60 percent of the national OPPS 

payment. The OPPS has consistently 

adopted the final fiscal year IPPS wage 

indices as the wage index values for 

adjusting the OPPS standard payment 

amounts for labor market differences. 

Thus, the wage index that applies to a 

particular acute care short-stay hospital 

under the IPPS would also apply to that 

hospital under the OPPS. We discuss 

our wage index policy in the CY 2010 

OPPS/ASC final rule with comment (74 

FR 60419). 

In accordance with section 

1886(d)(3)(E) of the Act, the IPPS wage 

index is updated annually. The IPPS 

wage index values that we adopted in 

the CY 2010 OPPS included all 

reclassifications that were approved by 

the Medicare Geographic Classification 

Review Board (MGCRB) for FY 2010. 

Reclassifications under section 508 of 

Public Law 108–173 (MMA) and the 

assignment of certain special exception 

wage indices that were extended by 

section 106(a) of Public Law 109–432 

(MIEA–TRHCA), section 117(a)(1) of 

Public Law 110–173 (MMSEA), and 

section 124 of Public Law 110–275 

(MIPPA) were set to terminate on 

September 30, 2009. Similar to our 

treatment of section 508 

reclassifications extended under Public 

Law 110–173 as described in the CY 

2009 OPPS/ASC final rule with 

comment period (73 FR 68586), we 

expected hospitals with section 508 

reclassifications to revert to their home 

area wage index, with out-migration 

adjustment if applicable, or a current 

MGCRB reclassification, from October 1, 

2009 to December 31, 2009 after section 

508 reclassifications expired. We also 

extended the assignment of certain 

special exceptions wage indices for 

certain hospitals from January 1, 2009 

through December 31, 2009, under the 

OPPS, in order to give these hospitals 

their special exception wage index 

under the OPPS for the same time 

period as under the IPPS. We refer 

readers to the Federal Register Notice 

published subsequent to the FY 2009 

IPPS final rule for a detailed discussion 

of the changes to the wage index values 

as required by section 124 of Public Law 

110–275 (73 FR 57888). Because the 

provisions of section 124 of Public Law 

110–275 expired in 2009 and because 

the Affordable Care Act had not yet 

passed, we did not propose to recognize 

section 508 reclassifications and wage 

indices for certain special exceptions 

hospitals for the OPPS wage indices for 

CY 2010 (74 FR 60419). 

Section 3137(a), as amended by 

section 10317, of the Affordable Care 

Act extended the wage index 

reclassifications originally designated 

under section 508 of Public Law 108– 

173 and certain special exception wage 

indices effective for services furnished 

on and after October 1, 2009 through 

September 30, 2010. We will implement 

the section 508 wage indices for OPPS 

payments for fiscal year 2010 under the 

OPPS. As indicated, the extended 

section 508 reclassifications will expire 

on September 30, 2010. Hospitals with 

a section 508 reclassification wage 

index will revert to their home area 

wage index, with out-migration 

adjustment if applicable, or a current 

MGCRB reclassification, from October 1, 

2010 to December 31, 2010 after the 

section 508 reclassifications expire on 

September 30, 2010. 

Further, as we did for CY 2009, the 

OPPS will recognize the special 

exception wage indices for certain 

hospitals from January 1, 2010 through 

December 31, 2010, under the OPPS, in 

order to give these hospitals the special 

exception wage index values under the 

OPPS for the same time period as under 

the IPPS. Finally, provisions of section 

3137(a) required us to recalculate wage 

indices for certain areas to exclude the 

wage data of section 508 and special 

exception hospitals in certain 

circumstances. This recalculation 

resulted in revised wage indices 

beginning on April 1, or midway 

through the fiscal year. To implement 

the same policy on a calendar year 

basis, the OPPS will adopt these revised 

wage indices midway through the 

calendar year beginning July 1, 2010. 

The revised wage indices that would 

apply for all providers that are paid 

under the OPPS are on public display 

on the CMS Web site at http:// 

www.cms.gov/AcuteInpatientPPS/ 

WIFN/itemdetail.asp. The revised wage 

indices also have been published by 

CMS in the June 2, 2010 Federal 

Register (75 FR 31147). We used these 

wage indices along with the wage 

indices that we finalized in our CY 2010 

OPPS/ASC final rule with comment 

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period and in effect in the OPPS 

between January 1, 2010 and June 30, 

2010 to calculate the budget neutrality 

adjustment for CY 2010 to the 

conversion factor discussed in 

I.A.3.above. As a result of the changes 

to the wage indices that are required by 

section 3137, we estimate a budget 

neutrality adjustment for the revised 

wage index of 0.9997 that we used for 

calculating the revised CY 2010 OPPS 

conversion factor of $67.241. 

We also note that section 3137(a), as 

amended by Section 10317, specifies 

that if the Section 508 or special 

exception hospital’s wage index 

applicable for the period beginning on 

October 1, 2009, and ending on March 

31, 2010, is lower than for the period 

beginning on April 1, 2010, and ending 

on September 30, 2010, the hospital 

shall be paid an additional amount that 

reflects the difference between the wage 

indices. To apply this provision to both 

inpatient and outpatient hospital 

payments we compared the two wage 

index values applicable for the period 

beginning on October 1, 2009, and 

ending on March 31, 2010, and for the 

period beginning on April 1, 2010, and 

ending on September 30, 2010 and 

assigned each Section 508 and special 

exception hospital the higher of the two 

wage index values. Consistent with our 

typical application of the wage index for 

these two sets of providers, we assigned 

the Section 508 providers their higher 

FY 2010 wage index from October 1, 

2009 through September 30, 2010 and 

assigned the special exception providers 

their higher FY 2010 wage index from 

January 1, 2010 through December 31, 

2010. 

5. Extension of Transitional Outpatient 

Payments (TOPs) for Small Rural 

Hospitals That Are Not Sole Community 

Hospitals and That Have 100 or Fewer 

Beds and Extension of TOPs to All SCHs 

(Including EACHs), Irrespective of the 

100 Bed Limitation 

Section 5105 of the Deficit Reduction 

Act of 2005 (DRA) reinstituted TOPs for 

covered OPD services furnished on or 

after January 1, 2006 and before January 

1, 2009, for rural hospitals having 100 

or fewer beds that are not sole 

community hospitals (SCHs). When the 

OPPS payment was less than the 

provider’s pre-BBA amount, the amount 

of payment was increased by 95 percent 

of the amount of the difference between 

these two amounts for CY 2006, by 90 

percent in CY 2007, and 85 percent in 

CY 2008. Section 147 of the Medicare 

Improvements for Patients and 

Providers Act of 2008 (MIPPA) extended 

the period of TOPs for small rural 

hospitals with 100 or fewer beds 

through December 31, 2009; when the 

OPPS payment was less than the 

provider’s pre-BBA amount, the amount 

of payment was increased by 85 percent 

of the amount of the difference between 

these two amounts for CY 2009. Section 

147 also provided 85 percent of the hold 

harmless amount from January 1, 2009 

through December 31, 2009 to sole 

community hospitals (SCHs) including 

essential access community hospitals 

(EACHs) with 100 or fewer beds. We 

note that EACHs are considered to be 

SCHs under section 

1886(d)(5)(D)(iii)(III) of the Act. 

Accordingly, under the statute, EACHs 

are treated as SCHs. 

Section 3121 of the Affordable Care 

Act extends the hold harmless provision 

for small rural hospitals with 100 or 

fewer beds and that are not sole 

community hospitals (as defined in 

section 1886(d)(5)(iii) of the Social 

Security Act) for an additional year 

through December 31, 2010, at 85 

percent of the hold harmless amount. 

Thus, for covered OPD services 

furnished on or after January 1, 2010 

through December 31, 2010, for which 

the PPS amount is less than the pre-BBA 

amount, the amount of payment shall be 

increased by 85 percent of the amount 

of the difference between these two 

amounts for CY 2010. In addition, 

section 3121 of the Affordable Care Act 

extended for an additional year the 

period of TOPs payments for SCHs (as 

defined in section 1886(d)(5)(iii) of the 

Act). As stated previously, EACHs fall 

within the definition of an SCH as set 

forth in 1886(d)(5)(iii) of the Act. 

Further, section 3121(b) of the 

Affordable Care Act amended section 

1833(t)(7)(D)(i)(III) of the Act to provide 

that in the case of covered OPD services 

furnished on or after January 1, 2010 

and before January 1, 2011, the 100-bed 

limitation will not be applied for SCHs 

(including EACHs) under 

1833(t)(3)(D)(i)(III) of the Act. Therefore, 

under section 1833(t)(3)(D)(i)(III) of the 

Act, payment will be increased under 

section 1833(t) of the Act to SCHs 

(including EACHs) for covered OPD 

services furnished on or after January 1, 

2010 through December 31, 2010, by 85 

percent of the amount of the difference 

between these two amounts when the 

PPS amount is less that the pre-BBA 

amount without regard to the 100-bed 

limitation. Cancer and children’s 

hospitals are permanently held harmless 

under section 1833(t)(7)(D)(ii) of the 

Social Security Act and continue to 

receive TOPs payments in CY 2010. 

B. Ambulatory Surgical Center Payment 

System 

1. Background 

In the CY 2010 OPPS/ASC final rule 

with comment period (74 FR 60596), we 

updated and finalized the CY 2010 ASC 

rates and lists of covered surgical 

procedures and covered ancillary 

services. We also corrected some of 

those ASC rates in a correction notice 

published in the Federal Register on 

December 31, 2009 (74 FR 69502). In 

that correction notice, we revised the 

ASC rates to reflect changes in the 

Medicare Physician Fee Schedule 

(MPFS) conversion factor and practice 

expense (PE) relative value units (RVUs) 

listed for some CPT codes in Addendum 

B to the CY 2010 MPFS final rule with 

comment period (74 FR 62017), which 

were incorrect due to certain technical 

errors and, consequently, were corrected 

in a correction notice to that final rule 

(74 FR 65449). We are also publishing 

a second correction notice in the 

Federal Register around the same time 

as this Notice to address changes to the 

ASC rates resulting from corrections to 

the PE RVUs and to the MPFS 

conversion factor identified subsequent 

to publication of the December 31, 2009 

correction notice. In this Notice, we 

discuss changes to the ASC payment 

rates due to changes to the OPPS and 

MPFS under the Affordable Care Act. 

The rates in this Notice also reflect 

technical corrections to the CY 2010 

ASC payment rates published in the CY 

2010 OPPS/ASC final rule with 

comment period as corrected by the two 

correction notices. None of these 

changes affected ASC payment 

methodologies or policies. 

2. Changes to the CY 2010 Ambulatory 

Surgical Center Payment System 

Required by the Changes to the Hospital 

Outpatient Prospective Payment System 

and the Medicare Physician Fee 

Schedule 

Under the revised ASC payment 

system, for most covered surgical 

procedures, we use the OPPS APCs to 

group services paid under the ASC 

payment system and we use the APC 

relative payment weights developed 

under the OPPS as the basis for ASC 

relative payment weights for calculating 

ASC payment rates. Specifically, we 

multiply an ASC relative payment 

weight derived from the OPPS APC 

relative weight by a budget neutral ASC 

conversion factor to calculate national 

unadjusted ASC payment rates each 

year. We refer to this as the standard 

ratesetting methodology for the ASC 

payment system. We transitioned to the 

standard ratesetting methodology over a 

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four-year period for procedures on the 

CY 2007 list of covered surgical 

procedures. CY 2010 is the third year of 

this four-year transition to fully 

implementing the standard ratesetting 

methodology. ASC payment rates for CY 

2010 are a transitional blend of 25 

percent of the CY 2007 ASC payment 

rate for a covered surgical procedure on 

the CY 2007 ASC list of surgical 

procedures and 75 percent of the 

payment rate for the procedure 

calculated under the standard 

ratesetting methodology. We discuss the 

standard ratesetting methodology and 

our transition to the full implementation 

of the standard ratesetting methodology 

in our August 2, 2007 ASC final rule (72 

FR 42491 through 42493, 42519 through 

42521). We update the ASC relative 

payment weights annually using the 

OPPS relative payment weights for that 

calendar year. Because the standard 

ratesetting methodology adopts the 

OPPS relative payment weights (not 

rates), reductions to OPPS payments 

created by the Affordable Care Act as 

discussed in section I.A.3. above do not 

impact payment made under the 

standard ratesetting methodology as the 

Affordable Care Act did not change any 

OPPS APC relative weights for CY 2010. 

However, the ASC payment system 

establishes the payment rates for several 

services using other methodologies that 

are impacted by the Affordable Care 

Act. Specifically, the calculation of 

device-intensive services, brachytherapy 

services, and bone density scans (a type 

of covered ancillary radiology service) 

under the ASC payment system rely 

directly on the actual payment rates 

under the OPPS and MPFS, which are 

impacted by the provisions of the 

Affordable Care Act discussed above 

and below. The Affordable Care Act 

changed the OPPS payment rates for any 

service where the OPPS conversion 

factor is used in its calculation, because 

the Affordable Care Act revised the CY 

2010 OPD fee schedule increase factor 

(see I.A.3. of this Notice). This change 

impacted payments for device-intensive 

services and brachytherapy services, 

which are dependent on payments 

established under the OPPS. 

We use a modified ASC methodology 

based on OPPS data to establish 

payment rates for the device-intensive 

procedures under the ASC payment 

system. ASC device-intensive services 

are covered surgical procedures that are 

assigned to the OPPS device-dependent 

APCs with a device offset percentage 

(i.e., the proportion of the APC relative 

weight attributable to devices under the 

OPPS) greater than 50 percent of the 

APC cost under the OPPS. Under the 

ASC payment system, we sum the 

device portion and the service portion 

to derive the ASC payment rate for each 

service’s device dependent APC. The 

device portion is equal to the device 

offset amount multiplied by the OPPS 

payment rate, which is the OPPS 

conversion factor multiplied by the 

OPPS relative payment weight, for each 

service’s device dependent APC. The 

service portion is equal to the ASC 

standard ratesetting methodology (or 

blended payment rates during the 

transition period) applied to the service 

portion of the OPPS relative payment 

weight (72 FR 42503 through 42508). 

Because CY 2010 OPPS APC payment 

rates have changed as a result of the 

Affordable Care Act, the device offset 

amount, and therefore the device 

portion of the ASC payment rate for 

device-intensive services also changed. 

The ASC Payment System also 

employs a modification to the standard 

ratesetting methodology to establish 

payment for brachytherapy sources. As 

discussed in our August 2, 2007 ASC 

final rule (72 FR 42498 to 42499), we 

finalized a policy to pay for 

brachytherapy services at the OPPS 

payment rates if OPPS rates were 

available, and if unavailable, to pay at 

contractor-priced rates. The CY 2010 

OPPS established payment rates for 

brachytherapy sources based on a 

relative weight and the OPPS 

conversion factor, which has changed as 

a result of the Affordable Care Act. 

Because the ASC payment system 

adopts the final payment rate from the 

OPPS, these payment rates have 

changed for the ASC payment system. 

Finally, payment for bone density 

scans under the ASC payment system is 

impacted by the changes made to the 

MPFS under section 3111 of the 

Affordable Care Act. Under the ASC 

payment system, payment for covered 

ancillary radiology services, which 

includes bone density scans, is capped 

at the lesser of the MPFS non-facility 

practice expense payment amount 

(calculated by multiplying the nonfacility practice expense RVU by the 

MPFS conversion factor) or the ASC rate 

developed according to the ASC 

standard ratesetting methodology. 

Section 3111 of the Affordable Care Act 

requires that, for CY 2010, payment 

under the MPFS for certain bone density 

scans be established at 70 percent of the 

product of the CY 2006 MPFS relative 

value units for the service, the CY 2006 

MPFS conversion factor and the CY 

2010 geographic adjustment factor for 

the service. Therefore, the final payment 

rate for these bone density scans 

depends on both the ASC payment and 

the MPFS non-facility practice expense 

payment amount, which changed under 

the Affordable Care Act. 

In addition to the changes made 

under the Affordable Care Act, the ASC 

payment rates in this Notice reflect the 

technical corrections to the CY 2010 

ASC payment rates published in the CY 

2010 OPPS/ASC final rule with 

comment period (74 FR 60316), and as 

corrected in a December 31, 2009 

correction notice and a second 

correction notice that will be published 

around the same time as this Notice to 

address changes to covered office-based 

and covered ancillary radiology services 

payment rates resulting from technical 

corrections to the MPFS non-facility 

practice expense payment amounts for 

CY 2010. Office-based procedures are 

procedures added to the ASC list of 

covered surgical procedures in CY 2008 

or later years that we determine are 

performed predominantly (more than 50 

percent of the time) in physicians’ 

offices and are paid based on the same 

methodology as covered ancillary 

radiology services (i.e., the lesser of the 

MPFS rate or the ASC rate under the 

standard methodology). We have 

already implemented the changes made 

by these correction notices. 

We note that the Department of 

Defense Appropriations Act, 2010 (Pub. 

L. 111–118), the Temporary Extension 

Act of 2010 (Pub. L. 111–144), and the 

Continuing Extension Act of 2010 (Pub. 

L. 111–157) extended a zero percent 

update for the MPFS from January 1, 

2010 through May 31, 2010. Because the 

Affordable Care Act changes are 

effective January 1, 2010, and because 

the public laws listed above authorize a 

zero percent update for the MPFS for CY 

2010 through May 31, 2010, this Notice 

incorporates a zero percent update for 

MPFS payment. On June 25, 2010 the 

Preservation of Access to Care for 

Medicare Beneficiaries and Pension 

Relief Act of 2010 (Pub L. 111–192) 

authorized a 2.2 percent update for the 

MPFS from June 1, 2010 through 

November 30, 2010. As is our standard 

practice, we will recalculate the revised 

ASC CY 2010 payment rates based on 

CY 2010 MPFS payment rates using the 

2.2 percent update factor, and we will 

make these revised payment rates 

available on our Web site under 

‘‘Addenda Updates’’ at http:// 

www.cms.gov/ASCPayment/ 

11_Addenda_Updates.asp#TopOfPage. 

Because of these changes to payment 

for device-intensive services, 

brachytherapy sources, and bone 

density scans created by the Affordable 

Care Act, and changes to MPFS nonfacility practice expense payment 

amounts and the MPFS conversion 

factor for covered office-based services 

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and ancillary radiology services created 

by technical corrections that we 

explained in the correction notices, we 

recalculated budget neutrality for the 

CY 2010 ASC payment system as part of 

this Notice. 

We discuss our budget neutrality 

methodology in the CY 2010 OPPS/ASC 

final rule with comment period (74 FR 

60625 through 60629). Using updated 

payment amounts for the OPPS and 

MPFS for the services affected by the 

Affordable Care Act and additional 

changes to the CY 2010 MPFS nonfacility practice expensive payment 

amounts based on the correction 

notices, we followed our standard 

scaling methodology to take into 

account the changes in the OPPS and 

MPFS payment amounts. We used the 

same claims data and scaling 

methodology described in the CY 2010 

OPPS/ASC final rule with comment 

period to calculate a revised CY 2010 

ASC payment weight scalar of 0.9556. 

(We previously finalized a CY 2010 ASC 

payment weight scalar of 0.9567 (74 FR 

60628)). After scaling the weights, we 

calculated a wage index adjustment of 

0.9996 and a final ASC conversion 

factor of $41.873. Both of these numbers 

did not change from what we previously 

finalized for CY 2010 (74 FR 60629). 

The Affordable Care Act did not impact 

the pre-floor, pre-reclassification wage 

indices that we adopt in the ASC 

payment system or the CPI–U. 

Therefore, the wage index adjustment 

and the final ASC conversion factor 

remained the same. We note that the 

technical corrections in the second 

correction notice impacted covered 

office-based procedures and covered 

ancillary radiology services with 

payment indicators of ‘‘P3’’ and ‘‘Z3’’. 

When we recalculated budget neutrality 

to address Affordable Care Act changes 

in this Notice, we also reflected the 

technical changes made in previous 

correction notices; therefore, the CY 

2010 payment for many covered officebased procedures and covered ancillary 

radiology services changed at least 

modestly. 

We historically also have reported the 

payment weight scalar that we would 

have calculated if we proposed to fully 

implement the ASC payment system in 

the coming calendar year without 

further transition. In the CY 2010 OPPS/ 

ASC final rule, we published a fully 

implemented CY 2010 ASC payment 

weight scalar of 0.9338 (74 FR 60674). 

Using the same claims data and budget 

neutrality methodology, including 

adjusting for changes in the wage index, 

and updating the OPPS and MPFS 

inputs, we calculated a revised fully 

implemented CY 2010 ASC payment 

weight scalar of 0.9326. 

Using the revised scaled ASC 

payment weights and the conversion 

factor of $41.873, the revised OPPS 

payment amounts, and the revised 

MPFS non-facility practice expense 

payment amounts, we recalculated the 

revised CY 2010 ASC payment rates for 

all services, including device-intensive 

services, brachytherapy sources, and 

office-based and ancillary radiology 

services, appearing in Addenda AA and 

BB of this notice. These payment rates 

are effective for services furnished on 

and after January 1, 2010 through 

December 31, 2010. These files also may 

be viewed as supporting documentation 

to this Notice at http://www.cms.gov/ 

ASCPayment. 

For purposes of applying the policy to 

reduce ASC payment for procedures 

involving devices furnished without 

cost or at reduced cost (74 FR 60613 

through 60618), the revised offset 

amounts of the ASC payment are not 

published as addenda to the ASC 

update rules but are available at 

http://www.cms.gov/ASCPayment under 

‘‘Annual Policy Files.’’ 

C. Elimination of Sunset for 

Reimbursement for All Medicare Part B 

Services in Hospitals and Clinics 

Operated by the Indian Health Service, 

Indian Tribes, or Tribal Organizations 

Section 2902 of the Affordable Care 

Act indefinitely extends Section 630 of 

the MMA, retroactive to January 1, 2010. 

The specific Part B services are: 

• Ambulance services; 

• Clinical laboratory services; 

• Part B drugs processed by the J4 A/ 

B MAC and the DME MACs; 

• Influenza and pneumonia 

vaccinations; 

• Durable medical equipment; 

• Therapeutic shoes; 

• Prosthetics and orthotics; 

• Surgical dressings, splints, and 

casts; and 

• Screening and preventive services 

not covered prior to the implementation 

of section 630 of the MMA 

Section 2902 of the Affordable Care 

Act indefinitely extends section 630 of 

the MMA to provide coverage for all 

Medicare Part B services listed above 

that were previously not covered under 

the Social Security Act. Hospitals 

operated by the Indian Health Service, 

Indian Tribes, or Tribal Organizations, 

however, will continue to be paid for 

Part B services under an all inclusive 

rate for hospital outpatient services 

rather than under the OPPS. 

II. Other Required Information 

A. Collection of Information 

Requirements 

This document does not impose 

information collection and 

recordkeeping requirements. 

Consequently, it need not be reviewed 

by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995. 

B. Waiver of Proposed Rulemaking 

We ordinarily publish a Notice of 

proposed rulemaking in the Federal 

Register and invite public comment 

prior to a rule taking effect in 

accordance with section 553(b) of the 

Administrative Procedures Act (APA) 

and section 1871 of the Act. In addition 

in accordance with section 553(d) of the 

APA and section 1871(e)(1)(B)(i) of the 

Act, we ordinarily provide a 30-day 

delay to a substantive rule’s effective 

date. For substantive rules that 

constitute major rules, in accordance 

with 5 U.S.C. 801, we ordinarily provide 

a 60-day delay in the effective date. 

None of the above processes or 

effective date requirements apply, 

however, when the rule in question is 

interpretive, a general statement of 

policy or a rule of agency organization, 

procedure or practice. They also do not 

apply when Congress, itself, has created 

the rules that are to be applied, leaving 

no discretion or gaps for an agency to 

fill in through rulemaking. 

In addition, an agency may waive 

notice and comment rulemaking, as well 

as any delay in effective date, when the 

agency for good cause finds that notice 

and public comment on the rule, as well 

as the effective date, are impracticable, 

unnecessary or contrary to the public 

interest. In cases where an agency finds 

good cause, the agency must incorporate 

a statement of this finding and its reason 

in the rule issued. 

The policies being publicized in this 

Notice do not constitute agency 

rulemaking. Rather, Congress, in the 

Affordable Care Act, has already 

required that the agency make these 

changes and we are simply notifying the 

public of the statutory requirements and 

their effect on payments made under the 

CY 2010 OPPS and ASC payment 

system. Specifically, we are notifying 

the public of the changes to payments 

for the CY 2010 OPPS that result from 

the reduction to the OPD fee schedule 

increase factor and the changes to the 

wage indices required by the Affordable 

Care Act. We are also notifying the 

public of the extension of section 508 

reclassifications and special exception 

wage indices for FY 2010 (which apply 

to the OPPS for CY 2010), as well as the 

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wage Indices resulting from Congress’ 

requirement that certain reclassification 

wage indices be recalculated (effective 

April 1, 2010) to account for such 

extensions. We are also notifying the 

public that Congress extended 

transitional outpatient payments (TOPs) 

for a rural hospital that has not more 

than 100 beds and that is not a sole 

community hospital as well as for sole 

community hospitals such that the sole 

community hospital need not satisfy the 

100-bed limitation for covered OPD 

service furnished on or after January 1, 

2010 and before January 1, 2011. We are 

notifying the public that Congress 

extended Medicare payments to the 

Indian Health Service, Indian Tribes, or 

Tribal Organizations for selected Part B 

services. We are notifying the public of 

changes made to ASC payment rates due 

to changes to the OPPS conversion 

factor under the Affordable Care Act. 

Lastly, we are notifying the public that 

Congress has changed payment for bone 

density scans under the MPFS, which 

may impact payment for these services 

furnished in ASCs on or after January 1, 

2010. As this Notice merely informs the 

public of these required modifications 

to the CY 2010 payment rates under the 

OPPS and, indirectly, to the ASC 

payment system, it is not a rule and 

does not require any notice and 

comment rulemaking. Additionally, for 

the ASC payment system, the payment 

rates announced in this Notice reflect 

technical corrections made to the MPFS 

that impact the ASC payment rates that 

we addressed in prior ASC correction 

notices; we are simply notifying the 

public of the effect on payment made 

under the CY 2010 ASC payment system 

based on these prior correction notices. 

To the extent that any of the policies 

articulated in this Notice constitute 

interpretations of Congress’s 

requirements or procedures that will be 

used to implement Congress’s 

directives, they are interpretative rules, 

general statements of policy and/or 

rules of agency procedure or practice, 

which are not subject to notice and 

comment rulemaking or a delayed 

effective date. 

However, to the extent that notice and 

comment rulemaking or a delay in 

effective date or both would otherwise 

apply, we find good cause to waive such 

requirements. Specifically, we find it 

unnecessary to undertake notice and 

comment rulemaking in this instance 

because the provisions of the Affordable 

Care Act are self-implementing, and 

further many are already effective and 

have been implemented. Therefore, we 

would be unable to change any of the 

policies governing the OPPS and ASC 

payment systems for CY 2010, or the 

other changes made by the Affordable 

Care in response to public comment on 

this Notice. As the changes outlined in 

this Notice have already taken effect and 

are a result of the statutory effective 

dates, it would also be impracticable to 

undertake notice and comment 

rulemaking. Additionally, this Notice 

does not make any changes to the 

policies and payment methodologies for 

the OPPS and ASC payment system that 

were finalized in the CY 2010 OPPS/ 

ASC final rule with comment period. 

Further, we believe it is in the public 

interest to have the accurate information 

and to have it as soon as possible and 

not delay its dissemination. For these 

reasons, we also find that a waiver of 

any delay in effective date, if it were 

otherwise applicable, is necessary to 

comply with the requirements of 

sections 2902, 3111, 3121, 3137, 3401 

and 10319 of the Patient Protection and 

Affordable Care Act and section 1105 of 

the Health Care and Education 

Reconciliation Act of 2010. Therefore 

we find good cause to waive notice and 

comment procedures as well as any 

delay in effective date, if such 

procedures or delays are required at all. 

III. Regulatory Impact Statement or 

Analysis 

A. Overall Impact 

Although this Notice merely 

announces provisions of the Affordable 

Care Act, and does not constitute a 

substantive rule, we are nevertheless 

preparing this impact analysis in the 

interest of ensuring that the impact of 

these changes are fully understood. The 

changes in this Notice are already in 

effect, with changes made to the OPPS 

pricer and the ASC payment system and 

have been announced through a Joint 

Signature Memorandum of instruction 

to Medicare contractors. We have, 

nevertheless, examined the impacts of 

this Notice as required by Executive 

Order 12866 (September 1993, 

Regulatory Planning and Review), the 

Regulatory Flexibility Act (RFA) 

(September 19, 1980, Pub. L. 96–354), 

section 1102(b) of the Social Security 

Act, the Unfunded Mandates Reform 

Act of 1995 (Pub. L. 104–4), Executive 

Order 13132 on Federalism, and the 

Congressional Review Act (5 U.S.C. 

804(2)). 

Executive Order 12866 directs 

agencies to assess all costs and benefits 

of available regulatory alternatives and, 

if regulation is necessary, to select 

regulatory approaches that maximize 

net benefits (including potential 

economic, environmental, public health 

and safety effects, distributive impacts, 

and equity). A regulatory impact 

analysis (RIA) must be prepared for 

major rules that have economically 

significant effects ($100 million or more 

in any 1 year) or adversely affect in a 

material way the economy, a sector of 

the economy, productivity, competition, 

jobs, the environment, public health or 

safety, or State, local, or tribal 

government or communities. 

We estimate that the effects of the 

OPPS provisions that are announced in 

this Notice will not result in 

expenditures exceeding $100 million in 

any 1 year and therefore are not 

economically significant. We estimate 

the difference between CY 2010 OPPS 

expenditures required by or resulting 

from the Affordable Care Act that are 

announced in this Notice, when 

compared to the estimated expenditures 

announced in our November 20, 2009 

CY 2010 final rule, (74 FR 60316) to be 

a decrease of approximately $98 

million. Because this Notice is not a 

major rule, and because, furthermore, 

the expected change in expenditures 

resulting from the Affordable Care Act 

does not reach the $100 million 

threshold for a RIA, we are not required 

to provide a regulatory impact analysis. 

However, because the changes 

required by the Affordable Care Act for 

the CY 2010 OPPS affect payment, we 

have prepared a regulatory impact 

analysis of changes to the OPPS 

payment system that, to the best of our 

ability, presents the costs and benefits of 

this Notice. Table I of this Notice 

displays the redistributional impact of 

the CY 2010 changes required by the 

Affordable Care Act on OPPS payment. 

The provisions of the Affordable Care 

Act result in a change in OPPS 

payments for CY 2010 as announced in 

this Notice compared to the CY 2010 

payments established under the CY 

2010 OPPS/ASC final rule appearing in 

the November 20, 2009 Federal 

Register. Table I presents only the 

changes in CY OPPS 2010 payments 

that result from the Affordable Care Act. 

We estimate that the effects of the 

changes to the CY 2010 OPPS and the 

non-facility MPFS PE RVUs resulting 

from the Affordable Care Act on the 

ASC payment system that are 

announced by this Notice will not 

exceed $100 million in any 1 year and, 

therefore, are not economically 

significant. Overall, we observe no 

change in aggregate expenditures under 

the CY 2010 ASC Payment System 

resulting from changes to the CY 2010 

OPPS and MPFS as required by the 

Affordable Care Act and by technical 

changes implemented by prior 

correction notices. 

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The RFA requires agencies to analyze 

options for regulatory relief of small 

businesses if a rule has a significant 

impact on a substantial number of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Many 

hospitals, other providers, ASCs, and 

other suppliers are considered to be 

small entities, either by being nonprofit 

organizations or by meeting the Small 

Business Administration (SBA) 

definition of a small business (hospitals 

having revenues of $34.5 million or less 

in any 1 year and ASCs having revenues 

of $10 million or less in any 1 year). 

(For details on the latest standards for 

health care providers, we refer readers 

to the SBA’s Web site at: http://sba.gov/ 

idc/groups/public/documents/ 

sba_homepage/serv_sstd_tablepdf.pdf 

(refer to the 620000 series).) 

For purposes of the RFA, we have 

determined that many hospitals and 

most ASCs would be considered small 

entities according to the SBA size 

standards. Individuals and States are 

not included in the definition of a small 

entity. Therefore, the Secretary has 

determined that this Notice will have a 

significant impact on a substantial 

number of small entities. We 

acknowledge that many of the affected 

entities are small entities. The 

discussion presented in this Notice and 

the impact analysis presented in Table 

I constitute our regulatory flexibility 

analysis of the impact of the provisions 

of the Affordable Care Act on small 

entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 603 of the 

RFA. With the exception of hospitals 

located in certain New England 

counties, for purposes of section 1102(b) 

of the Act, we now define a small rural 

hospital as a hospital that is located 

outside an urban area and has fewer 

than 100 beds. Section 601(g) of the 

Social Security Amendments of 1983 

(Pub. L. 98–21) designated hospitals in 

certain New England counties as 

belonging to the adjacent urban areas. 

Thus, for OPPS purposes, we continue 

to classify these hospitals as urban 

hospitals. 

We believe that the changes to the 

OPPS announced by this Notice affect 

both a substantial number of rural 

hospitals as well as other classes of 

hospitals and that the effects on some 

may be significant. Therefore, the 

Secretary has determined that this 

Notice has a significant impact on the 

operations of a substantial number of 

small rural hospitals. Specifically, 

section 3121 of the Affordable Care Act 

extends TOPs payment for small rural 

hospitals that are not sole community 

hospitals and that have 100 or fewer 

beds and payments for SCHs (including 

EACHs), that meet applicable 

requirements regardless of the 100-bed 

limitation for covered OPD services 

furnished on and after January 1, 2010 

through December 31, 2010. See our 

discussion of this change in section 

I.A.5 above. In addition, section 3137 as 

amended by section 10317 of the 

Affordable Care Act extends section 508 

reclassifications and special exception 

wage index values from October 1, 2009 

through September 30. It also resulted 

in the recalculation of wage index 

values to exclude the wage data of 

section 508/special exception hospitals 

in certain circumstances, thereby 

changing the final wage index values, 

effective April 1 for IPPS and July 1 for 

OPPS. These wage index changes affect 

some small rural hospitals. See section 

I.A.4 of this Notice for a discussion of 

the wage index changes required by 

Affordable Care Act. We also anticipate 

that Affordable Care Act changes 

impacting ASC payment in general will 

impact payment to rural ASCs. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. That threshold 

level is currently approximately $133 

million. This Notice will not mandate 

any requirements for State, local, or 

tribal governments, nor will it affect 

private sector costs. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

costs on State and local governments, 

preempts State law, or otherwise has 

Federalism implications. We have 

examined the provisions included in 

this Notice in accordance with 

Executive Order 13132, Federalism, and 

have determined that they will not have 

a substantial direct effect on State, local 

or tribal governments, preempt State 

law, or otherwise have a Federalism 

implication. 

The following analysis, in 

conjunction with the remainder of this 

document, demonstrates that this Notice 

is consistent with the regulatory 

philosophy and principles identified in 

Executive Order 12866, the RFA, and 

section 1102(b) of the Act. The changes 

to the payment amounts under CY 2010 

OPPS that are required by the 

Affordable Care Act and that are 

announced in this Notice will affect 

payments to a substantial number of 

small rural hospitals and a small 

number of rural ASCs, as well as other 

classes of hospitals and ASCs, and some 

effects may be significant. 

The impact analysis presented in the 

CY 2010 OPPS/ASC final rule (74 FR 

60662 through 60673) showed the 

estimated impact of changes to 

payments for CY 2010 OPPS compared 

to the estimated payments for CY 2009 

OPPS. In contrast, the impact analysis 

presented in this Notice shows the 

estimated impact of changes to payment 

for CY 2010 as a result of the 

implementation of the changes required 

by the Affordable Care Act. The 

Affordable Care Act changed payments 

for services for which the payment is 

calculated using the conversion factor. 

In addition, we note that none of the 

APC relative weights changed because 

the relative weight calculations are not 

made using the conversion factor. For 

an assessment of distributional impact 

of changes to the relative weights 

between CY 2009 and CY 2010 please 

see the CY 2010 OPPS/ASC final rule 

(74 FR 60667 through 60672). Therefore, 

the decrease of 0.1 percent reflects 

changes to the total OPPS payment that 

would have been made in CY 2010 

absent the provisions of the Affordable 

Care Act (This impact does not include 

the impact of changes to TOPs). 

However, we note that hospitals 

continue to receive a positive payment 

increase relative to CY 2009. When we 

compare the estimated total payments 

for the CY 2010 OPPS, including the 

provisions of the Affordable Care Act, to 

the estimated total payments for the CY 

2009 OPPS, we find that for CY 2010, 

we expect that hospitals will see an 

aggregate increase in total OPPS 

payment of approximately $500 million, 

compared to CY 2009. 

Effects of OPPS Changes in This Notice 

This Notice announces changes to the 

OPPS and ASC payments for services 

furnished in CY 2010 that are required 

as a result of Sections 3121, 3401, 3137 

and 10319 of the Patient Protection and 

Affordable Care Act and section 1105 of 

the Health Care and Education 

Reconciliation Act of 2010. These 

changes are discussed in detail in I.A of 

this Notice. Under the recalculated 

OPPS payment rates announced in this 

Notice, we estimate that the revised 

update to the conversion factor and 

other adjustments as provided by the 

statute will decrease total OPPS 

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payments by 0.1 percent in CY 2010 

compared to payment rates under the 

November 20, 2009 CY 2010 OPPS/ASC 

final rule. 

The distributional impacts presented 

here are the projected effects of changes 

to the CY 2010 payments on various 

hospital groups, comparing the 

estimated CY 2010 OPPS payments 

under this Notice to the estimated 

payments under the November 20, 2009 

CY 2010 OPPS/ASC final rule. We post 

on the CMS Web site our hospitalspecific estimated payments for CY 

2010 with the other supporting 

documentation for this Notice. To view 

the hospital-specific estimates of CY 

2010 OPPS payments that we calculated 

including the effects of the changes 

made by the Affordable Care Act, we 

refer readers to the CMS Web site at: 

http://www.cms.gov/ 

HospitalOutpatientPPS/. Select 

‘‘regulations and Notices’’ from the left 

side of the page and then select ‘‘CMS– 

1504–N’’ from the list of regulations and 

Notices. The hospital-specific file layout 

and the hospital-specific file are listed 

with the other supporting 

documentation for this Notice of 

changes to the CY 2010 payment rates. 

We show hospital-specific data only for 

hospitals whose claims were used for 

modeling the impacts shown in Table I 

below. We do not show hospital-specific 

impacts for hospitals whose claims we 

were unable to use. We refer readers to 

section II.A.2. of the CY 2010 OPPS 

final rule (75 FR 60347) for a discussion 

of the hospitals whose claims we do not 

use for ratesetting and impact purposes. 

We estimate the effects of the 

individual policy changes by estimating 

payments per service, while holding all 

other payment policies constant. We use 

the best data available, but do not 

attempt to predict behavioral responses 

to our policy changes. In addition, we 

do not make adjustments for future 

changes in variables such as service 

volume, service mix, or number of 

encounters. 

Table 1 below shows the estimated 

impact of the changes on hospitals’ CY 

2010 OPPS payment as a result of the 

Affordable Care Act. Historically, the 

first line of the impact table, which 

estimates the change in payments to all 

hospitals, has always included cancer 

and children’s hospitals, which are held 

harmless to their pre-BBA payment-tocost ratio. We also are including CMHCs 

in the first line that includes all 

providers because we included CMHCs 

in our CY 2010 weight scaler estimate 

discussed in our November 20, 2009 CY 

2010 OPPS/ASC final rule with 

comment period (74 FR 60408). 

We present separate impacts for 

CMHCs in Table 1 because CMHCs are 

paid under only two APCs for services 

under the OPPS: APC 0172 (Level 1 

Partial Hospitalization (3 units of 

service)) and APC 0173 (Level II Partial 

Hospitalization (4 or more units of 

service)). We note that CMHCs are also 

a different provider type. 

The estimated decrease in the total 

payments made under the CY 2010 

OPPS is a result of the decrease in the 

OPD fee schedule update factor as 

required by sections 3401 and 10319 of 

the Patient Protection and Affordable 

Care Act and section 1105 of the Health 

Care and Education Reconciliation Act 

of 2010, and the influence of the 

changes to the wage index required by 

section 3137 as amended by section 

10317 of the Affordable Care Act. The 

distributional impacts presented do not 

include assumptions about changes in 

volume and service mix. The enactment 

of Public Law 108–173 on December 8, 

2003, provided for the additional 

payment outside of the budget 

neutrality requirement for wage index 

for specific hospitals reclassified under 

section 508. Section 3137 as amended 

by section 10317 of the Affordable Care 

Act extended these section 508 

reclassifications for October 1, 2009 

through September 30, 2010. The 

amounts attributable to these 

reclassifications are incorporated into 

the CY 2010 estimates in the final 

column of Table 1. 

Table 1 shows the estimated 

redistribution of hospital and CMHC 

payments among providers between 

payments under the November 20, 2009 

CY 2010 OPPS/ASC final rule published 

for CY 2010 and the CY 2010 payments 

announced in this Notice as a result of 

APC reconfiguration and recalibration 

(Column 2; which remain unchanged 

from the publication of the CY 2010 

OPPS on November 20, 2009 because 

there were no changes made by the 

Affordable Care Act to the assignment of 

services to APCs or the median costs 

from which the scaled relative weights 

are derived); wage index changes 

(Column 3; which reflect the changes 

made by section 3137 (amended by 

section 10317) of the Affordable Care 

Act)); the combined impact of the APC 

recalibration, wage index effects, and 

the reduction applied to the OPD fee 

schedule increase factor (which is 

revised as required by sections 3401 and 

10319 of the Patient Protection and 

Affordable Care Act and section 1105 of 

the Health Care and Education 

Reconciliation Act of 2010) which is 

used to update the conversion factor 

(Column 4); and, finally, estimated 

redistribution considering all payments 

for CY 2010 under this Notice relative 

to all CY 2010 payments under the 

November 20, 2009 CY 2010 OPPS/ASC 

final rule (Column 5). Because the 

reduction that applies to the OPD fee 

schedule increase factor as required by 

the Affordable Care Act, is applied 

uniformly across services for which the 

conversion factor is used to calculate 

OPPS payment, observed redistributions 

of payments in the impact table for 

hospitals largely depend on the impact 

of the wage index changes under section 

3137 including changes to the wage 

index for the second half of the year and 

the extension of the section 508 

reclassifications for part of CY 2010. 

However, total payments made under 

this system and the extent to which the 

changes required by Affordable Care Act 

would redistribute money during 

implementation also depend on volume, 

practice patterns, and the mix of 

services billed by various groups of 

hospitals, which CMS cannot forecast. 

Overall, the revised CY 2010 OPPS 

rates are expected to have a negative 

effect for providers paid under the 

OPPS, resulting in a 0.1 percent 

estimated decrease in Medicare 

payments compared to CY 2010 OPPS 

rates announced in the November 20, 

2009 final rule with comment period. 

Removing cancer and children’s 

hospitals, because their payments are 

held harmless to the pre-BBA ratio 

between payment and cost, and CMHCs 

because they are a different provider 

type paid under two specific APCs, 

suggests that the required changes will 

continue to result in a 0.1 percent 

estimated decrease in Medicare 

payments to all other hospitals. 

Table 1 contains the standard content 

that is provided in every OPPS impact 

table published in the Federal Register. 

Specifically, Column 1 contains the 

number of hospitals in total and by 

category for which we calculated an 

impact. These are the same hospitals 

whose claims were used for ratesetting 

and modeling of impacts for the CY 

2010 OPPS that was published on 

November 20, 2010. Column 2 displays 

the CY 2010 APC changes due to the 

reassignment and recalibration under 

this Notice, relative to the November 20, 

2009 CY 2010 OPPS/ASC final rule (74 

FR 60431). Because nothing in the 

Affordable Care Act changed APC 

assignment or calibration, there are no 

changes in this column. Column 3 

displays the effect of the new wage 

index changes required by the 

Affordable Care Act compared to the 

previous FY 2010 wage index adopted 

in the November 20, 2009 CY 2010 

OPPS/ASC final rule. Although there 

are changes to the wage indices for some 

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hospitals for half of the year because of 

changes made by the Affordable Care 

Act, the impact does not rise to a tenth 

of a percent for any category of provider. 

Column 4 displays the effect of the 

budget neutrality changes between the 

November 20, 2009 CY 2010 OPPS/ASC 

final rule and the payment rates for CY 

2010 as announced by this Notice, 

specifically the reduction applied to the 

OPD fee schedule update factor as a 

result of the Affordable Care Act. 

Because not all OPPS payments are 

based on the conversion factor (e.g. 

separately paid drugs and biologicals 

are paid at ASP+4 percent for CY 2010), 

the impact of the 0.25 percentage point 

reduction to the OPD fee schedule 

update factor does not affect payment 

for all services and therefore the impact 

of the reduction is slightly less than 

0.25. Column 5 displays the combined 

impact of all changes made for CY 2010, 

including changes in the section 508 

reclassification wage index as required 

by the Affordable Care Act relative to 

payments announced in the November 

20, 2009 CY2010 OPPS/ASC final rule. 

Therefore it incorporates the changes in 

payment that are outside of budget 

neutrality for section 508 and certain 

special exception hospitals. The 

increase in payment outside budget 

neutrality for section 508 hospitals is 

present throughout column 5 and is 

isolated as a 1.8 percent increase in the 

last row of Table 1. 

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5. Estimated Effect of This Notice on 

Beneficiaries 

For services for which the beneficiary 

pays a copayment of 20 percent of the 

payment rate, the beneficiary share of 

payment will increase for services for 

which the OPPS payments will rise and 

will decrease for services for which the 

OPPS payments will fall. In all cases, 

the statute limits beneficiary liability for 

copayment for a procedure to the 

hospital inpatient deductible for the 

applicable year. The CY 2010 hospital 

inpatient deductible is $1,100. 

In order to better understand the 

impact of changes in copayment on 

beneficiaries, we modeled the percent 

change in total copayment liability. We 

estimate, using the claims of the 4,222 

hospitals and CMHCs on which our 

modeling is based, that total beneficiary 

liability for copayments continues to be 

22.6 percent, as estimated in the 

November 20, 2009 CY 2010 OPPS/ASC 

final rule (74 FR 60673). To assess 

whether there are changes to the 

aggregate percentage of beneficiary 

liability, we recalculated the percentage 

using the revised conversion factor and 

wage indices on which the revised 

payments being announced in this 

Notice are based. 

6. Conclusion 

The changes announced in this Notice 

will affect all classes of hospitals and 

CMHCs. We estimated that most classes 

of hospitals will experience minor 

losses or remain neutral and that all 

classes of hospitals will experience 

negative updates in OPPS payments in 

CY 2010 compared to the payments 

announced in the November 20, 2009 

CY 2010 OPPS/ASC final rule as a result 

of the provisions of the Affordable Care 

Act. 

Table 1 demonstrates the estimated 

distributional impact of the OPPS 

budget neutrality requirements that are 

expected to result in a 0.1 percent 

decrease in payments for all services 

paid under the OPPS in CY 2010 under 

this Notice when compared to the 

November 20, 2009 CY 2010 OPPS/ASC 

final rule, after considering the OPD fee 

schedule increase factor (revised by the 

Affordable Care Act), wage index 

changes (including the effects of the 

extension of the section 508 

reclassifications), estimated payment for 

outliers (which did not change as a 

result of the Affordable Care Act), and 

changes to the pass-through payment 

estimate (which did not change as a 

result of the Affordable Care Act). The 

accompanying discussion, in 

combination with the rest of this Notice, 

constitutes a regulatory impact analysis. 

7. Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/circulars/ 

a004/a-4.pdf), in Table 2, we have 

prepared an accounting statement 

showing the CY 2010 estimated hospital 

OPPS incurred benefit impact 

associated with the changes to the CY 

2010 OPD fee schedule increase factor 

and budget neutral wage index changes 

(as revised by the Affordable Care Act) 

shown in this Notice based on the 

baseline for the 2010 Medicare Trustees 

Report. All estimated impacts are 

classified as transfers. 


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45850 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45851 


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45852 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45853 


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45854 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45855 


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45856 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45857 


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45858 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45859 


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45860 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45861 


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45862 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45863 


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45864 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45865 


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45866 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45867 


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45868 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45869 


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45870 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45871 


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45872 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45873 


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45874 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45875 


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45876 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45877 


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45878 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45879 


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45880 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45881 


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45882 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45883 


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45884 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45885 


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45886 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45887 


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45888 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45889 


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45890 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45891 


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45892 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45893 


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45894 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45895 


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45896 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45897 


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45898 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45899 


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45900 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45901 


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45902 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45903 


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45904 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45905 


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45906 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45907 


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45908 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45909 


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45910 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45911 


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45912 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45913 


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45914 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45915 


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45916 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45917 


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45918 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45919 


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45920 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45921 


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45922 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45923 


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45924 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45925 


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45926 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45927 


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45928 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45929 


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45930 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45931 


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45932 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45933 


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45934 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45935 


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45936 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45937 


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45938 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45939 


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45940 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45941 


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45942 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45943 


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45944 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45945 


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45946 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45947 


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45948 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45949 


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45950 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45951 


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45952 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45953 


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45954 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45955 


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45956 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45957 


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45958 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45959 


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45960 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45961 


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45962 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45963 


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45964 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45965 


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45966 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45967 


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45968 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45969 


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45970 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45971 


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45972 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45973 


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45974 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45975 


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45976 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45977 


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45978 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45979 


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45980 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45981 


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45982 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45983 


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45984 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45985 


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45986 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45987 


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45988 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45989 


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45990 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45991 


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45992 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45993 


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45994 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45995 


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45996 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45997 


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45998 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 45999 


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46000 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46001 


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46002 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46003 


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46004 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46005 


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46006 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46007 


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46008 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46009 


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46010 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46011 


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46012 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46013 


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46014 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46015 


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46016 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46017 


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46018 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46019 


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46020 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46021 


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46022 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46023 


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46024 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46025 


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46026 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46027 


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46028 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46029 


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46030 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46031 


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46032 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46033 


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46034 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46035 


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46036 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46037 


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46038 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46039 


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46040 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46041 


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46042 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46043 


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46044 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46045 


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46046 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46047 


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46048 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46049 


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46050 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46051 


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46052 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46053 


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46054 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46055 


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46056 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46057 


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46058 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46059 


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46060 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46061 


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46062 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46063 


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46064 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46065 


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46066 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46067 


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46068 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46069 


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46070 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46071 


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46072 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46073 


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46074 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46075 


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46076 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46077 


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46078 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46079 


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46080 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46081 


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46082 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46083 


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46084 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46085 


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46086 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46087 


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46088 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46089 


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46090 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46091 


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46092 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46093 


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46094 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46095 


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46096 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46097 


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46098 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46099 


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46100 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46101 


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46102 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46103 


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46104 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46105 


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46106 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46107 


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46108 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46109 


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46110 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46111 


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46112 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46113 


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46114 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46115 


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46116 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46117 


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46118 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46119 


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46120 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46121 


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46122 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46123 


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46124 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46125 


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46126 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46127 


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46128 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46129 


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46130 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46131 


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46132 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46133 


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46134 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46135 


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46136 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46137 


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46138 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46139 


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46140 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46141 


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46142 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46143 


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46144 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46145 


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46146 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46147 


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46148 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46149 


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46150 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46151 


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46152 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46153 


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46154 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46155 


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46156 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46157 


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46158 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46159 


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46160 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46161 


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46162 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46163 


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46164 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46165 


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46166 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 


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Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 46167 


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46168 Federal Register / Vol. 75, No. 148 / Tuesday, August 3, 2010 / Notices 

(Catalog of Federal Domestic Assistance 

Program No. 93.778, Medical Assistance 

Program; No. 93.773 Medicare—Hospital 

Insurance Program; and No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: June 18, 2010. 

Marilyn Tavenner, 

Acting Administrator and Chief Operating 

Officer, Centers for Medicare & Medicaid 

Services. 

Approved: June 30, 2010. 

Kathleen Sebelius, 

Secretary. 

[FR Doc. 2010–16400 Filed 7–2–10; 2:30 pm] 

BILLING CODE 4120–01–C 


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